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Behavioural Therapies for Tic Disorders and Tourette Syndrome: CBIT, HRT and ERP

Updated: Aug 30, 2023


An overview of the three main behavioural therapies for tic disorders and Tourette Syndrome, by Dr Morvwen Duncan, the founder of The Lotus Psychology Practice and a Senior Clinical Psychologist at the national Tic Disorder Service within the NHS.



What are Tic Disorders?

Tic disorders are a neurodevelopmental disorder, characterised by involuntary movements and sounds, known as tics. Common motor tics include eye blinking, shrugging or head jerking, and common vocal tics may including sniffing, throat clearing or whistling.


Tic disorders refer to a spectrum of movement disorders:

  • Transient tic disorder –motor or vocal tics that last for a short time, often under a few months. This is very common, affecting 10-20% of young people. If you visit a nursery you will see lots of young children experiencing small blinking or sniffing tics.

  • Chronic tic disorder – motor or vocal tics that persist for more than 1 year, which is less common, affecting 5% of young people.

  • Tourette Syndrome – multiple motor and vocal tics present for at least 1 year.


Although Tourette Syndrome is the least common tic disorder, it is thought to affect one school child in every hundred.



Tics can have a significant impact on a young persons life. They can impact on their ability to read or write in lessons, their ability to talk to or play with their friends, or take part fully in their hobbies, whether that is football, horse riding or skateboarding. In severe cases, the tics may cause physical injury or harm.


What are Behavioural Therapies for Tics?

The European clinical guidelines for Tourette syndrome and other tic disorders recommend at first, a thorough assessment of tics, as they can often co-occur with other neurodevelopmental difficulties such as attentional difficulties (ADHD), autism spectrum disorder (ASD), obsessive compulsive disorder (OCD) anxiety, depression and low self-esteem. Following a confirmation of a tic diagnosis, the first line intervention is psychoeducation - to learn about tics, what causes them, the typical course of tics and how to explain tics to other people. If the tics are causing an impact on a young persons life, behavioural therapies are indicated as a treatment for tic disorders and Tourette syndrome. They have been found to reduce tic severity, tic-related impairment and to improve quality of life, and are as effective as medication for tics (Rizzo et al, 2018). The improvements have been shown to last over time, with 40% of patients reported partial remission from their tic disorder 11 years after the intervention (Espil et al, 2022).


Behavioural therapies for tics include Habit Reversal Training (HRT), which has been expanded into the Comprehensive Behavioural Intervention for Tics (CBiT) and Exposure and Response Prevention (ERP). All behaviour therapies aim to help people get used to tolerating a ‘pre-monitory urge’ or what we call a ‘tic alert’ - uncomfortable signals from the body that let you know that a tic is about to come. Some young people have described this an itch, or the feeling you might get before you sneeze. The therapies then focus on increasing a person’s ability to tolerate the urge, and eventually the tic urge will fade.


To help explain the principles of behaviour therapies for tics, imagine that last time you had a mosquito bite, and how itchy and uncomfortable it was. What did you do? If like most people, you scratched it, you might have noticed you felt a short relief… and then after a few moments that itch came back stronger! If you are in the no scratching group – well done! I’m sure you felt uncomfortable and itchy in the short term, but by resisting the urge to scratch the bite, you broke the cycle and reduced the urge to itch over time. In this example, we can think of tics as the bite, and the urge to scratch as the tic urge or tic alert.


As you can imagine, behavioural therapies for tics are hard work, and require a lot of motivation!

 

1. Habit Reversal Training (HRT)

The research into HRT began as far back as the 1970’s. The first stage of HRT is to become more aware of the ‘tic alerts’. You then create a ‘tic blocker’ (known as a competing response), an action which makes it impossible to let the tic out at the same time.


There are 5 rules the tic blocker must abide by:

1. It must be able to be done anywhere - at school, in church, in the cinema...

2. ...and without any props (put the sunglasses down)

3. It can be held for more than a minute.

4. It must be incompatible with the tic.

5. And finally, it must be less annoying or embarrassing to you than the tic itself.

 

2. Cognitive Behaviour Interventions for Tics (CBiT)

CBiT expands on HRT, and is made up of 6 key parts:

1. Psychoeducation: learning all about tics, and what your individual triggers are.

2. Self awareness: learning how to recognise those ‘tic alert’ or urges.

3. Relaxation skills: which is proven to reduce and calm tics.

4. Social support: this includes ensuring a young person is understood and supported by family, friends and school.

5. Habit Reversal Training

6. Competing Response (Tic Blocker)

 

3. Exposure and Response Prevention (ERP)

As in the previous therapies, ERP aims to build up a tolerance to the urge that comes before a tic. Level 1 starts with holding in all the tics in for as long as you can, in spite of the tic urge (response prevention). Once you master this for up to five minutes, you then go onto Level 2, where we introduce ‘exposure’ to the urge, to practice resisting the urge for longer and longer, and at times that are important to you.


Tics themselves can have a significant impact on a child's life, although they are often accompanied by co-occurring difficulties such as attentional difficulties (ADHD), autism spectrum disorder (ASD), obsessive compulsive disorder (OCD) anxiety, depression and low self-esteem. Therefore, it is important that a thorough assessment is undertaken to develop an individualised support package for you or your child. If you would like to learn more about tics, or think that behavioural interventions for tics may be helpful for you or your child you can get in touch with us at The Lotus Psychology Practice for a free of charge initial consultation. We are able to offer behavioural interventions in person or remotely.


See Resources page for more information on tics and Tourette Syndrome.

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